Doxycycline for the Treatment of Lyme Disease in Young Children.

BACKGROUND: Doxycycline is considered the first-line treatment of Lyme disease in adolescents and adults, but largely disproven concerns of permanent tooth staining prevented its use and evaluation in children <8 years old. We sought to describe short-term adverse effects and treatment failures among young children receiving oral doxycycline for Lyme disease. METHODS: We completed a 2-pronged evaluation of children with Lyme disease treated with doxycycline. We performed a retrospective case series of patients <8 years old who were diagnosed with Lyme disease and treated with doxycycline. We then performed a telephone follow-up survey study of the patients' parents to gather additional details regarding clinical outcomes and adverse reactions to doxycycline. Descriptive statistics were calculated. RESULTS: A total of 32 patients were identified through the retrospective case series and 18 participated in the follow-up survey. The most common clinical diagnosis (22/32; 69%) was single erythema migrans. Seven (22%) had neurological Lyme disease. Three patients (9%) stopped doxycycline treatment prematurely due to adverse effects. During telephone follow-up, 2 children were reported to have dental staining. No patients were identified with treatment failure during the retrospective case series. On telephone follow-up, 3 patients had residual symptoms after treatment, though none were convincing of treatment failure. CONCLUSIONS: Our study suggests that doxycycline is generally well-tolerated and an effective treatment of Lyme disease in young children. Prospective, observational studies with long-term assessment of dental staining and clinical outcomes are needed. Alternative antibiotics, principally amoxicillin, remain the preferred treatment of non-neurological Lyme disease manifestations in young children, but doxycycline is likely a safe and effective alternative when needed.

Serologic Testing for Rocky Mountain Spotted Fever in a Low-Incidence Region.

BACKGROUND: Tick-borne diseases have grown in incidence over recent decades. As a result, diagnostic testing has become more common, often performed as broad antibody-based panels for multiple tick-transmitted pathogens. Rocky Mountain spotted fever (RMSF) is rare in our region yet may cause severe morbidity, leading to diagnostic screening in low-risk patients. We sought to describe trends in RMSF diagnostic testing, rate of IgG seropositivity, and clinical features of those tested. METHODS: We performed a retrospective chart review of patients ≤21 years old undergoing testing for RMSF and/or with an ICD-9/10 code for RMSF. Patients were categorized by infection likelihood based on clinical and laboratory criteria adapted from Centers for Disease Control and Prevention's (CDC) case definition of spotted fever rickettsioses. Clinical data were collected and analyzed with descriptive statistics. RESULTS: One hundred and seventy patients were included. 5.8% met CDC criteria for rickettsial infection, 6.5% had an elevated IgG titer but lacked suggestive symptoms, and 87.6% had a negative IgG titer. Many patients tested were unlikely to have RMSF, including 50% lacking fever, 20% lacking any RMSF "classic triad" symptoms, 13% without acute illness, and 22% tested during months with low tick activity. Convalescent serology was performed in 7.6% of patients and none underwent Rickettsia rickettsii polymerase chain reaction (PCR) testing. CONCLUSIONS: Diagnostic testing was frequently performed in patients unlikely to have RMSF. We identified many opportunities for improving test utilization. Reserving testing for those with higher pretest probability, performing convalescent serology, and utilizing PCR may improve the accuracy of RMSF diagnosis and reduce clinical challenges stemming from inappropriate testing.

Tricuspid Valve Endocarditis in Four Patients with Unrepaired Restrictive Perimembranous Ventricular Septal Defects.

Congenital heart disease (CHD) is the most common predisposing factor for pediatric infective endocarditis (IE). Although patients with unrepaired ventricular septal defects (VSDs) are at greater risk of IE than those without CHD, the American Heart Association (AHA) considers VSDs to be relatively low risk and therefore does not recommend antibiotic prophylaxis against IE. Even among patients with VSDs who develop IE, current AHA and European Society for Cardiology (ESC) guidelines do not recommend surgical VSD closure, despite the potential for a second IE event. We present a case series of four children with small, restrictive, perimembranous VSDs who developed tricuspid valve (TV) IE. All four experienced delayed diagnosis and secondary complications, including three with septic pulmonary emboli. All four patients ultimately underwent surgical VSD closure. These cases highlight the importance of recognizing IE as a possible cause of prolonged fever in children, even among those with even 'low-risk' CHD. The cases also draw attention to the potential benefits of VSD closure in patients who develop IE.

Metagenomic Next-Generation Sequencing for Infectious Disease Diagnosis: A Review of the Literature With a Focus on Pediatrics.

Metagenomic next-generation sequencing (mNGS) is a novel tool for identifying microbial DNA and/or RNA in blood and other clinical specimens. In the face of increasingly complex patients and an ever-growing list of known potential pathogens, mNGS has been proposed as a breakthrough tool for unbiased pathogen identification. Studies have begun to explore the clinical applicability of mNGS in a variety of settings, including endocarditis, pneumonia, febrile neutropenia, osteoarticular infections, and returning travelers. The real-world impact of mNGS has also been assessed through retrospective studies, documenting varying degrees of success and limitations. In this review, we will explore current highlights of the clinical mNGS literature, with a focus on pediatric data where available. We aim to provide the reader with a deeper understanding of the strengths and weaknesses of mNGS and to provide direction toward areas requiring further research.

Metagenomic Next-Generation Sequencing (mNGS): SARS-CoV-2 as an Example of the Technology's Potential Pediatric Infectious Disease Applications.

Metagenomic next-generation sequencing (mNGS) has emerged as a potentially powerful tool in clinical diagnosis, hospital epidemiology, microbial evolutionary biology, and studies of host-pathogen interaction. The SARS-CoV-2 pandemic provides a framework for demonstrating the applications of this technology in each of these areas. In this Supplement, we review applications of mNGS within the discipline of pediatric infectious diseases.

One Affectionate Puppy: A Case of Septic Arthritis Due to Staphylococcus Pseudintermedius.

We describe a case of septic arthritis caused by Staphylococcus pseudintermedius, a common colonizer of dogs that has emerged as a rare human pathogen. Our patient presented with ankle pain and swelling and was treated adequately with cefazolin/cephalexin and arthrotomy. S. pseudintermedius is often misidentified as other coagulase-positive staphylococcal species and has high rates of methicillin and nonpenicillin antibiotic resistance.

Two Neonates With Postnatally Acquired Tickborne Infections.

Neonatal tick bites place infants at risk for acquiring infections that have rarely or never been documented in this age group. We describe 2 rare cases of tickborne infection in neonates. The first patient presented with multiple erythema migrans and fever, leading to a diagnosis of early disseminated Lyme disease. The second patient presented with irritability, fever, and worsening anemia due to babesiosis. Both infants had been bitten by arthropods fitting the description of ticks before the onset of symptoms. Our cases demonstrate the clinical course of 2 common tickborne infections occurring at an atypical age, opening the door to new, complex questions for which little guiding data exists. As tickborne infections become more prevalent, we expect other clinicians will be faced with similarly challenging neonatal cases. Providers must use past experience and a keen eye to identify neonates with tickborne infections and sort through their optimal diagnosis and management. In this article, we raise some of the questions we faced and discuss our conclusions.

Knowledge, attitudes, and practices regarding dengue infection among public sector healthcare providers in Machala, Ecuador.

BACKGROUND: Dengue fever is a rapidly emerging infection throughout the tropics and subtropics with extensive public health burden. Adequate training of healthcare providers is crucial to reducing infection incidence through patient education and collaboration with public health authorities. We examined how public sector healthcare providers in a dengue-endemic region of Ecuador view and manage dengue infections, with a focus on the 2009 World Health Organization (WHO) Dengue Guidelines. METHODS: A 37-item questionnaire of dengue knowledge, attitudes, and practices was developed and administered to dengue healthcare providers in Machala, Ecuador. Survey focus areas included: "Demographics," "Infection and Prevention of Dengue," "Dengue Diagnosis and the WHO Dengue Guide," "Laboratory Testing," "Treatment of Dengue," and "Opinions Regarding Dengue." RESULTS: A total of 76 healthcare providers participated in this study, of which 82 % were medical doctors and 14 % were nurses. Fifty-eight percent of healthcare professionals practiced in ambulatory clinics and 34 % worked in a hospital. Eighty-nine percent of respondents were familiar with the 2009 WHO Dengue Guidelines, and, within that group, 97 % reported that the WHO Dengue Guide was helpful in dengue diagnosis and clinical management. Knowledge gaps identified included Aedes aegypti mosquito feeding habits and dengue epidemiology. Individuals with greater dengue-related knowledge were more likely to consider dengue a major health problem. Only 22 % of respondents correctly reported that patients with comorbidities and dengue without warning signs require hospital admission, and 25 % of providers reported never admitting patients with dengue to the hospital. Twenty percent of providers reported rarely (≤25 % of cases) obtaining laboratory confirmation of dengue infection. Providers reported patient presumptive self-medication as an ongoing problem. Thirty-one percent of healthcare providers reported inadequate access to resources needed to diagnose and treat dengue. CONCLUSION: Participants demonstrated a high level of knowledge of dengue symptoms and treatment, but additional training regarding prevention, diagnosis, and admission criteria is needed. Interventions should not only focus on increasing knowledge, but also encourage review of the WHO Dengue Guidelines, avoidance of presumptive self-medication, and recognition of dengue as a major health problem. This study provided an assessment tool that effectively captured healthcare providers' knowledge and identified critical gaps in practice.